Synopsis

The Grand Jury investigated
the need for Automated External Defibrillators (AEDs) in Santa Cruz
County, how they are currently being
deployed, and what policies are in place for their use in saving the lives of
sudden cardiac arrest(SCA) victims.

An estimated 325,000 lives are lost
each year in the United States due to sudden
cardiac
arrest.[1]From
October 2004 through September 2006, 484 people were victims of sudden cardiac arrest in Santa
Cruz County alone.[2]
With the recent advances in technology, the modern
AED units are simple and relatively low cost. Many lives
could be saved if they were made available and used within the
first few minutes after the onset of sudden cardiac arrest.
Although fire and ambulance
services in the county are
well equipped and have an excellent reputation for effective medical response,
their ability to reach a patient who is suffering from sudden
cardiac arrestin time is highly problematic. The
solution lies with AEDs being more widely distributed at key
sites throughout the county.

In providing what is fast
becoming a “standard of care,” the
county
must keep uptodate with
technology, national trends and the legal liability associated with failure to
be proactive. The county should re-examine
its policy and its requirements for the placement of AEDs as recommended in this
report.

Definitions

AEDAutomated External Defibrillator — a computerized
medical device that automates
the process of administering an electrical shock to the
heart to restore its natural rhythm.

Advanced Life Support (ALS)Medical care provided by emergency
medical technicians trained to assess a patient's condition,
administer drugs, defibrillate and provide advanced airway management prior to
transportation to the hospital.

AMRAmerican Medical
Response — a private ambulance
service that coordinates with emergency services agencies
in the county for first responder Advanced
Life Support service.
AMR is the sole provider of medical transport in the county.

Basic Life Support (BLS)Basic
Life Support consists of a number of life-saving techniques focused on the ‘ABCs’ of pre-hospital
emergency care: Airway, Breathing and Circulation.BLS
generally does not include the use of drugs or invasive skills, but
with advances inAEDs may now include
defibrillation.

CPR
Cardio-Pulmonary Resuscitation.

EMSIA
Emergency Medical Services Integration Authority — a
combination of county fire districts and departments that work
together with American Medical Response to
provide Advanced Life Support medical services in Santa Cruz County.

PADPublic Access Defibrillator — an AED that isavailable
in public and/or private places where large numbers of people gather or people
who are at high risk for heart attacks live.

Standard of CareThe level of service that
the average, prudent provider in a given community would practice.

VF/VTVentricular Fibrillation/Ventricular Tachycardia — chaotic heartrhythms
that can be restored to a natural spontaneous rhythm through
defibrillation.

Background

Heart disease is a serious
public health issue. In the United States, at least 61 million
people have cardiovascular disease, resulting in an estimated 1 million
deaths per year. About one-third of these deaths, 300,000 to 400,000, are due
to sudden cardiac arrest, the sudden and unexpected loss of heart function.[3]

Most often,suddencardiac
arrest is due to chaotic beating of the large chambers of the heart, called
ventricular fibrillation.Typically, its victims
have no warning and quickly collapse and lose consciousness.
The only treatment that can save their lives is the quick use of a
defibrillator, a medical device that administers an electrical shock to the
heart to restore its synchronous pumping rhythm. Defibrillators work by giving
the heart a controlled electric shock that has the chance to resynchronize the
contraction of the heart muscle and restore its normal rhythm.

The overall survival
rate for out-of-hospital cardiac arrest is 6.4 percent nationally and
6 percent in Santa Cruz County.[4]Immediate
treatment with defibrillationcan improve
the odds of survival significantly — resulting in greater
than 90 percent survival. Every minute of delay decreases the survival
rates by 10 percent; after 10 minutes without
defibrillation, it is highly unlikely that asudden
cardiac arrest victimwill survive.

Defibrillators are available in
two forms, manual and automated. Only trained medical professionals are
qualified to use manual defibrillators. Manual defibrillators require
interpretation of the patient’s condition and an understanding of the
capabilities of the defibrillator to deliver an effective and safe shock.

Recently, as a result of
technological advances and the development of special computer applications, a
new kind of defibrillator has become available. Today’s AED uses
embedded computer chips and sophisticated programming to
analyze heart rhythms quickly and accurately and determine if a shock should be
given. It will only deliver
a shock if the readings indicate that one is necessary. This automation
makes it possible for non-medically trained individuals to deliver
the same life-saving treatment as medical professionals without
risking an accidental or inappropriate shock. Most modern AEDs are
equipped with synthesized voice instructions telling the
user how to proceed in the case of a cardiac emergency. This new equipmentis very
easy to use. In fact, in one study,
untrained sixth graders took only 30 seconds longer than trained
emergency service technicians to prepare a patient for a shock.[5]

Another advantage of modern
automated defibrillators is the fact that, like most
electronic equipment, they have becomemore
affordable and available to the general public. In the past, their
cost put them out of the reach of most people, but today
they can be purchased through retail and online outlets for prices ranging from
about $1,000 to $2,000.

The American Heart Association
has recognized four critical factors associated with improved survival rates
from sudden
cardiac arrest in communities. More
people survive when this sequence of events, called the Chain of Survival,
happens as quickly as possible. These four steps are:

Early Access — recognizing that a cardiovascular
emergency exists and immediately notifying the Emergency Medical Services
(EMS) system, usually by calling 911.

Early CPR — starting CPR immediately after cardiac
arrest to circulate blood to vital organs buys time for the victim until
defibrillation can be administered.

Early Defibrillation — defibrillation of the victim
as soon as equipment arrives.

Establishing a viable chain
of survival
in a community requires an integrated plan that relies on the cooperation of
local government agencies and ordinary citizens to know what to do and be
prepared to take action when an emergency occurs.

Findings

Status
of Emergency Services in Santa Cruz County

1.The
911 system for most of Santa Cruz County is administered through the Santa Cruz
Consolidated Emergency Communications Center, commonly called Net Com.
Additional public safety answering points for the 911 system are in Scotts
Valley and at the University of California’s Santa Cruz campus.

Response: The
Santa Cruz Consolidated Emergency Communications Center (NetCom) PARTIALLY
AGREES.In addition to the primary public
safety answering points (PSAP) mentioned within the Finding, it should be noted
that Cal Fire maintains a secondary PSAP
located in Felton which receives transferred 9-1-1 calls relating to fire
incidents occurring within the unincorporated areas of the County not serviced
by a Fire District.

Response: The
Santa Cruz County Emergency Medical Services Integration Authority (EMSIA)
AGREES.It is important to note that many 911
calls are made by cell phones. When 911 calls are made by cell phones on or
close to major roadways, the California Highway Patrol acts as the public
safety answering point. Calls are then routed to the appropriate jurisdictional
dispatch center.

2.Net
Com is an up-to-date, modern
facility. Dispatchers have access to computer-aided
dispatch systems that allow them to rapidly send
police, fire, and medical assistance when needed.For medical
calls involving a person not breathing, such as sudden cardiac arrest,
Net Com was able to dispatch Emergency Medical
Service units within 60 seconds 92 percent of the time in 2006.

Response:
The EMSIA PARTIALLY AGREES.The EMSIA consists of 12 Fire
agencies in Santa Cruz County; Aptos/La Selva Fire District, Ben Lomond Fire
District, Boulder Creek Fire District, Branciforte Fire District, Central Fire
District, Felton Fire District, Pajaro Valley Fire District, City of Santa Cruz
Fire Department, Scotts Valley Fire District, UCSC Fire Department, City of
Watsonville Fire Department, and Zayante Fire District and acts as a liaison
between the fire service, the County, AMR, and other EMS related entities. It
is the five agencies listed in the finding , not the EMSIA, that actually
provide advanced life support services. The remaining agencies provide basic
life support (BLS) medical services within their jurisdictions.

4.The
remainder of the county receives first responder Basic Life Support medical
services from a variety of smaller fire departments and the California
Department of Forestry.

Response:
The EMSIA MOSTLY AGREES.As described in #3, the EMSIA BLS
agencies provide BLS Services to much of the county. The California Department
of Forestry and Fire Protection (CALFIRE) provides BLS through its contract as
the Santa Cruz County Fire Department. CALFIRE and Santa Cruz County Fire
Department are not member agencies of the EMSIA.

5.American
Medical Response (AMR), a private ambulance service, coordinates with the EMSIA
agencies for first responder ALS service and through its contract with the
County of Santa Cruz is the sole provider of medical transport in the county.

Response:
The EMSIA AGREES.

6.EMSIA
fire agencies are able to provide a paramedic to a medical emergency within
eight minutes of dispatch 90 percent of the time in urban
areas.

Response:
The EMSIA AGREES.Urban areas, as defined for the
purposes of this finding, are the jurisdictional service areas of the EMSIA ALS
agencies (Aptos/La Selva Fire District, Central Fire District, Scotts Valley
Fire District, City of Watsonville Fire Department and City of Santa Cruz Fire
Department). The actual performance level hovers around 94% of all emergency
calls within eight minutes.

7.AMR
is able to provide an ambulance to a medical emergency within 12 minutes of
dispatch 90 percent of the time.

Response:
The EMSIA AGREES.

A fire
department paramedic is the first one to arrive at a medical emergency
about 60 percent of the time.

Response:
The EMSIA AGREES.

The expectations of service are
carefully listed in the emergency services’ contracts
issued by the county to American Medical Response. AMR
coordinates its services with the EMSIA to ensure the best possible
service to the citizens of Santa Cruz County.

Response: The EMSIA AGREES.

AED Distribution and Training

10.Manual defibrillators, such as those carried
by fire department and AMR paramedics, are expensive and complex
and require significant training and experience to be effective.
Conversely, automated external defibrillators
(AEDs) are reasonably priced and simple to operateby
anyone with a minimum of training.

11.Santa Cruz
County does not have a comprehensive policy regarding
the distribution and installation of AEDs in public locations.

Response: The
County AGREES.The
County is not required by State law to adopt a policy regarding distribution
and installation of Automatic External Defibrillators (AEDs) in public
locations.

12.AEDs are
carried in police patrol cars in Scotts Valley. No other law enforcement agenciesin
the county require AEDs in their vehicles.

Response: The Santa Cruz County Sheriff's Office
PARTIALLY AGREES.It is not known which law enforcement
agencies in the county require AEDs in their vehicles.

Response:
The Santa Cruz Police Department PARTIALLY AGREES.Our agency does not require AEDs in all
of our patrol vehicles but provides an AED in our supervisor’s vehicle and
outside of the main lobby of our police department.

Response:
The Scotts Valley Police Department AGREES:Scotts Valley Police carries AEDs in our
cars. We do not know what the requirements are in other county law enforcement
agencies.

Response: The
Capitola Police Department DISAGREES.Currently, the Capitola Police Department
has five AEDs at its disposal. One AED is deployed at the Police Department for
use by staff either in the field or at headquarters. An additional AED is
located in City Hall for use by City Hall staff serving the public. Three
additional AEDs are available and routinely assigned to the Lifeguard Unit
located at the Capitola Main Beach, one AED in the Supervisors patrol vehicle
and one unit deployed in a primary police cruiser.Additional AEDs are scheduled for acquisition
in late 2007 or early 2008.Several of
these AEDs have been in service for approximately two years.Eventually, the Police Department intends to
equip each primary patrol unit with an AED, requiring acquisition of three to
four more devices. It is important to note that an AED also are available at
the Capitola Mall and readily available to department staff working at the
Capitola Police Department’s Community Outreach Center.

Response: The
Watsonville Police Department PARTIALLY DISAGREES.Capitola Police Department has many
of them. Whether any other police department has them in the car, we don’t
know. We accept the jury’s statement that Scotts Valley Police Department does.

13.The
locations of AEDs in the county are not available to Net Com dispatchers.

Response:
NetCom AGREES.

14.When
AEDs are deployed in public buildings, they are often not visible and therefore
not accessible when needed.

15.CPR
classes, including training in the use of AEDs, are available through a variety
of sources in the county.

Need
for AEDs

16.While
immediate CPR can buy valuable time for a sudden cardiac
arrest victim, defibrillation is the only treatment that can save the victim’s life
by restoring the heart’s spontaneous rhythm.

Response: The EMSIA AGREES.Defibrillation is the most definitive
intervention shown to restore spontaneous circulation in cardiac arrest patients.
However, studies also show thateffective
CPR significantly enhances the success of all defibrillation attempts. Proper
compression and ventilation (especially with 100% oxygen) is therefore a
critical component of this “chain of survival.”To this end, early 911 access is also crucial; the study here in Santa
Cruz County showed higher survival rates with witnessed arrests vs. unwitnessed
arrests.

17.People of
any age may suffer sudden cardiac arrest and die
suddenly.

Response: The EMSIA AGREES.While the predominance of sudden
cardiac arrests occur among elderly patients, it is true that no age group is
immune from sudden cardiac arrest.

18.Sudden
cardiac arrest is different from a heart attack although coronary
artery disease may reduce heart circulation and eventually result in SCA.

Response:
The EMSIA AGREES.

19.Often the
first sign that a person is vulnerable to ventricular fibrillation is an attack
that results in sudden cardiac arrest and
death.

Response:
The EMSIA AGREES.

20.In Santa
Cruz County, approximately 250 people per year
are victims of out-of-hospital sudden cardiac arrest. From
October 2004 through September 2006, more than half of these victims (51 percent) were not
candidates for resuscitation, mostly because too much
time had elapsed before emergency medical services could be activated.[6]

Response: The EMSIA AGREES.The patients in this study who were
not candidates for resuscitation fell into one of three groups:

1. Patients
who had been in cardiac arrest for too long before EMS was activated (the
majority of patients were in this category);

2. Patients
who had signed paperwork indicating that they did not wish to be resuscitated,
usually due to the presence of a terminal illness;

3.Patients
who had suffered traumatic injuries (58 cases) and were deemed unviable prior
to a resuscitation attempt.

21.Some common
causes for sudden cardiac arrest include
asphyxia due to drowning or other oxygen deprivation, congenital heart
conditions, sudden blows to the chest, electrocution, and coronary artery
disease.

Response: The
EMSIA AGREES.The vast majority of cases of sudden
cardiac arrest in adult patients across all age groups can be attributed to the
presence of coronary artery disease and/or cardiomyopathy, and the subsequent
fatal arrythmias which can occur in these patients. The most common cause of
cardiac arrest in children is respiratory arrest secondary to a host of causes
including drowning, foreign body airway obstruction, and respiratory disease.

Sudden blows to the chest, electrocution, and congenital heart conditions are
very rare causes of sudden cardiac arrest in any community.“Asphyxia” refers to fatal anoxia from
respiratory failure (from drowning, foreign body airway obstruction, severe
asthma attacks, etc.) and is a more common cause of SCA in any community, but
certainly far less common than cardiac etiologies.

22.The worst
combinationfor
cardiac arrest survival is if patients collapse without witnesses, and when
discovered, receive no bystander CPR while emergency services personnel are enroute.
In a two-year period in Santa Cruz County, only two of 215 patients in this
situation had their hearts begin to beat again, and
neither survived. When sudden cardiac arrest was
witnessed and immediate CPR was administered, nearly a
quarter of the victims regained pulses and 10 percent survived. The
survival rate jumped to 19 percent when EMS professionals witnessed cardiac
arrest and could begin treatment
immediately.There were 16 EMS-witnessed
cases in the two-year period, and three of those were found
to be in ventricular fibrillation (as opposed to those with no electrical
activity or pulse). All three were successfully resuscitated with defibrillation
only.[7]

Response:
The EMSIA AGREES.

23.Some
experts believe that a connection may exist between the use of ‘Tasers’
by law enforcement and sudden cardiac arrest in some
individuals.

Response from the EMSIA:This concept is very hotly debated
among legal, medical and law enforcement experts. Much of the medical data at
this time suggests that sudden, in-custody deaths may in fact be attributable
to a medical phenomenon known as “excited delirium.”

Excited delirium is thought to occur when individuals — often, but not always,
drug or alcohol intoxicated — develop central nervous system dysfunction which
leads to bizarre, violent behavior.When
force of any kind is subsequently used—
wrestling with the patient, batons, Tasers, pepper spray — the patient may
experience respiratory and cardiac arrest. There is no indication that Tasers
particularly are implicated in in-custody deaths any more than any other use of
force to try to control and contain a violent or non-compliant subject who
suffers from this phenomenon.

24.To
improve the survival rate of victims of out-of-hospital cardiac arrest in Santa
Cruz County, the
Emergency Medical Services Integration Authority recommends “promulgating
citizen CPR programs, Public Access Defibrillator (PAD) programs, and
continued rapid EMS response using all the latest AHA (American
Heart Association) recommendations for CPR, defibrillation, and
advanced life support care.”[8]

Response:
The EMSIA AGREES.

Laws
related to AEDs

25.Effective
July 1, 2007, the State of California will require all health clubs
to be equipped with AEDs on site and establish a
program of training, maintenance, and record keeping.

Response:
The EMSIA AGREES.

26.Good
Samaritan laws protect most citizens from liability if they take action in a
medical emergency, which includes using an AED. Conversely, lawsuits have been
filed against organizations such as amusement parks and airline companies for
not having AEDs readily available.

27.AEDs are
now required at FAA governed airports and on all commercial airliners.

Conclusions:

1.In
Santa Cruz County, the American Heart Association’s recommended
‘Chain of Survival’ for victims of sudden cardiac arrest is incomplete.
Specifically, the availability of early CPR and early defibrillation is
lacking.

Although Net Com and the Emergency Medical
Services Integration Authority cooperate to ensure
advanced
life support (ALS) services are sent to medical emergencies
as quickly as possible, even the most rapid dispatch and transit times by
Net Com and ALS providers will rarely get a defibrillator to the victim
within the three- to five-minute window recommended by the American
Heart Associatjon for best survival, especially in outlying
areas of the county.

Modern AEDs are simple to use and can improve the
chances of surviving sudden cardiac arrest if they are
deployed in the community and if there is a base population of trained
citizens able to step in when a medical emergency requiring the use of an
AED occurs.

When AEDs are deployed in the community, they need to
be made visible and readily accessible to the public so they can be used
immediately.

Net Com staff could improve response time in cases of
sudden
cardiac arrest if they knew the locations of nearby AEDs.

Deaths due to sudden cardiac arrest can
be reduced through a combined program of public education in
CPR and effective public access defibrillator
(PAD) implementation.

The availability of an AED is becoming the expected
‘standard of care’ in many situations.

The availability of AEDs
in county buildings—
and their deployment in sudden cardiac arrest incidents — may
protect
the county from possible litigation and
financial liability.

Providers of AEDs may be protected from liability if
they comply with simple regulations regarding training, maintenance,
record keeping, and medical oversight.

Recommendations

The Santa Cruz County Health
Services Agency should establish a public education program to enhance the
community’s knowledge and awareness of CPR and
the use of AEDs as a life-saving measure.

Response from the County:The recommendation is being implemented in conjunction with the
Emergency Medical Care Commission’s Public Information and Education
Subcommittee. The Subcommittee will continue to monitor local out-of-hospital
cardiac arrest data and is working closely with Dominican Hospital to improve
the survival rate.

The locations of AEDs in the county should be entered
in Net Com’s Computer-Assisted Dispatch
system.

Response
from NetCom:Requires further analysis and may not
be implemented because it is beyond this agency’s scope of service. Netcom
computer systems possess the ability to be programmed with AED location data
tied to fixed telephone locations which would become available to call-takers upon
call answering. While the technical capability and capacity exists, there is
currently no program or system available to collect and update this location
data, nor is there a requirement for businesses and individuals to “register”
their AEDs by location. Furthermore, it is beyond the scope of our agency to
mandate a registration and to be responsible for the collection of such data. In
the event that a responsible agency should someday register, collect, and
update AED location data and make it available to our Agency in an electronic
format, we in turn could enter it into our computer systems and make it
available to call-takers handling 9-1-1 emergency calls.In the meantime, it is important to note that
our computerized Emergency Medical Dispatch (EMD ProQA) software is configured
to prompt call-takers to question callers who report “cardiac” incidents as to
the availability and accessibility of an AED. In the event that a caller
answers “Yes” to this prompt, EMD ProQA provides medically approved, step-by-step
instructions which allows NetCom call-takers to “walk the caller through” the
operation of an AED.

Santa CruzCounty
should require AEDs in county buildings
with more than 100 employees or daily visitors and
in county detention facilities, including
Juvenile Hall.

Response from the County:This recommendation will not be implemented at this time. While the
County strongly supports the idea, funds are not available to purchase and
install AEDs in all county buildings with more than 100 employees.The County will look for funding
opportunities and will consider a phased in approach as part of County budget
considerations.

Santa Cruz County should encourage the use of
AEDs in the following public
locales and private settings:

§·Public schools

§·Public swimming pools

§·Public libraries

§·Large concerts and other public
events

§·Public golf courses

§·Churches with a capacity of 100 or
more

§·Private schools

§·Private recreation clubs

§·Medium to large hotels and motels

§·Shopping centers

§·Medical and dental offices

§·Private golf courses

·Senior citizen centers and care facilities

Response from the County:The recommendation is in the process of
being implemented by the Emergency Medical Care Commission’s Public Information
and Education Subcommittee that is focusing on cardiac care and stroke
prevention. The Emergency Medical Services Program will also be adding
information about AEDs to the program’s webpage.

The county and each city should equip
law enforcement vehicles with AEDs.

Response: The Santa Cruz County Sheriff's Office
AGREES.This recommendation has not yet been implemented
but will be implemented in the future. The Sheriff's Office has just purchased
a few AEDs for deployment.However, due
to the large number of Sheriff's vehicles, full deployment will have to occur
in planned stages, along with the training of staff.

Response from the Santa Cruz Police Department:The recommendation will not be
implemented. Our agency is not a primary responder for medical calls and the
Santa Cruz Fire Department staffs paramedics [are] primary responders for such
emergencies. In order to outfit our patrol vehicles the department would have
to outlay over $50,000 in equipment and training costs.

Response: The Scotts Valley Police Department AGREES:
The Scotts Valley Police Department has
carried AEDs in our patrol vehicles for several years now.

Response from the Capitola Police Department:
The Capitola Police Department agrees and
is the process of acquiring additional AEDs and the requisite training and
certification required to effectively deploy the devices in each primary patrol
vehicle, office site and the Capitola Lifeguard Unit.

Response: The Watsonville Police Department AGREES.Watsonville Police Department will
put them in the next two-year budget cycle; FY2009/11 for consideration by the
City Council.

The county should establish a
mechanism to ensure that once AEDs are
deployed by public agencies, those
responsible meet the requirements needed to
shield the county from liability by providing training, maintenance,
record keeping and medical oversight.

Response from the County:State law is clear that individuals and agencies that purchase and place
AEDs are shielded from liability if they follow the requirements to maintain
them and conduct training as required by the State.

The county should establish a
reporting and inspection mechanism to ensure
that AEDs deployed in the community are identified by Net Com
and therebyviable
in case of an emergency.

Response from the County:Emergency medical dispatchers at NetCom routinely ask callers reporting
suspected cardiac arrests to quickly look around for an AED.It would not be feasible to conduct
inspections to ascertain where AEDs are located and to establish and correct a
database with any regularity. It is anticipated that in the near future AEDs
will be as prolific as fire extinguishers.

The county should develop a strategy
for implementing a meaningful public access defibrillator program that
meets the criteria of the American Heart Association and American Red
Cross recommendations.

Response from the County:The recommendation is in the process of being implemented by the
Emergency Medical Care Commission’s Public Information and Education
Subcommittee that is focusing on cardiac care and stroke prevention. The
Emergency Medical Services Program will also be adding information about AEDs
to the program’s webpage.

The county should explore funding opportunities to
pay for an expanded public access defibrillator program
from both public and private sources, possibly enlisting the aid of
community service organizations.

Response from the County:The recommendation is being implemented by the Emergency Medical Care
Commission’s Public Information and Education Subcommittee that is focusing on
cardiac care and stroke prevention.

Commendation

Santa Cruz County’s emergency
services teams and organizations for providing the most efficient and
responsive services possible under current conditions.